Introduction

Get a useful overview of the key issues in ostomy surgery in this section. There is a quick reference to the anatomy and organ systems involved, the common complications that your patients may encounter after surgery and tips and tools to help.

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Assessing quality of life in ostomy patients

People with an ostomy can have many concerns – fear of leakage, embarrassment about their body, worries about becoming a burden to family and friends. When these concerns stop people from doing the things they enjoy, it puts their quality of life at risk.

With the Stoma-QoL tool, healthcare professionals now have a standard and a common language with which to assess quality of life for people with a stoma. You can use the tool to monitor quality of life over time in the same person – or compare quality of life between patients.

Stoma-QoL is:

Specifically designed for people with a stoma – all questions are based on input from people with a stoma

Validated – tested in representative ostomy populations in different countries

Reliable – weighted to emphasize the issues that are most critical to the respondent’s quality of life

Basic anatomy

Anatomy and physiology of the digestive and urinary systems

Digestive system

The digestive tract stretches some nine metres from the mouth to the anus and is divided into different sections. Each section processes food in a specific way to prepare it for the next section of the digestive tract, until the waste finally leaves the intestinal tract as faeces.

Functions of the digestive system:

Mechanical and chemical breakdown of food into basic nutrients

Absorption of nutrients into the blood

Processing and elimination of waste

A number of organs work alongside the digestive tract, producing fluids and enzymes to aid indigestion:

Salivary glands in the mouth

Acid fluids in the stomach

Liver and gallbladder

Pancreas

The gastrointestinal tract comprises:

Mouth

Oesophagus

Stomach

Small intestine – jejunum & ileum

Large intestine – colon

Rectum

Anus

The intestinal wall consists of several layers

The small intestine is approximately 5–7 m long in adults. It is divided into three main parts:

Duodenum

Jejunum

Ileum

The jejunum and ileum are connected to the abdominal wall by the mesentery. The mesentery contains arteries, veins and lymph vessels that ensure the transport of oxygen and nutrients to and from the small intestine.

The large intestine is approximately 1–2 m long in adults. It is divided into six parts:

Ascending colon

Transverse colon

Descending colon

Sigmoid colon, the S-shaped structure

Rectum: final part of the digestive tract. Stool collects in the rectal ampulla. A filled ampulla initiates the urge to empty the bowels

The urinary system

The urinary system

The overall function of the urinary system is to produce and drain urine, removing waste products and regulating the blood's fluid balance. The entire urinary system is located behind the digestive tract.

The urinary system consists of:

Two kidneys

Two ureters

Bladder

Urethra

The kidneys are two bean-shaped structures that continuously filter the blood, removing waste products and excess water, and balancing fluids and electrolytes. This filtering process results in the production of urine.

The ureters are ducts that carry urine from the kidneys to the bladder.

The bladder has a dual function. It is both a reservoir that stores urine and a pump that expels urine from the body. The muscle in the bladder wall pushes the urine out.

The urethra is a duct connecting the bladder to the outside of the body.

Basic surgical procedures

Colostomy surgery

Colostomy

In a colostomy operation, part of the colon is brought to the surface of the abdomen to form the stoma. A colostomy is usually (but not always) created on the left-hand side of the abdomen. Output consistency depends on where the colostomy is located:

Ascending colostomy: Output can range from liquid to pasty consistency and may be irritating to the skin

Transverse colostomy: Output is somewhat formed

Descending / sigmoid colostomy: Output is formed

Because a stoma has no muscle to control defecation, the output it produces will need to be collected using a stoma pouch.

There are two different types of colostomy surgery: End colostomy and loop colostomy.

End colostomyIf parts of the large intestine (colon) or rectum have been removed, the remaining large intestine is brought to the surface of the abdomen to form a stoma. An end colostomy can be temporary or permanent. The temporary solution is relevant in situations where the diseased part of the bowel has been removed and the remaining part of the bowel needs to rest before the ends are joined together. The permanent solution is chosen in situations where it is too risky or not possible to reconnect the two parts of the intestine.

Loop colostomyIn a loop colostomy, the bowel is lifted above skin level and held in place with a stoma rod. A cut is made on the exposed bowel loop, and the ends are then rolled down and sewn onto the skin. In this way, a loop stoma actually consists of two stomas (double-barrelled stoma) that are joined together. The loop colostomy is typically a temporary measure performed in acute situations. It can also be carried out to protect a surgical join in the bowel.

Ileostomy surgery

Ileostomy

In an ileostomy operation, a part of the small intestine called the ileum is brought to the surface of the abdomen to form the stoma. Ileostomy surgery is typically performed in cases where the end part of the small intestine is diseased, and is usually made on the right-hand side of the abdomen. Depending on the disease process, ileostomies may be permanent or temporary.

The stool can range from a liquid to pasty consistency, and contains enzymes that are irritating to the peristomal skin. Because a stoma has no muscle to control defecation, the output will need to be collected in a pouch.

There are two different types of ileostomy surgery:

End ileostomy

An end ileostomy is created when part of the large intestine (colon) is removed (or simply needs to rest) and the end of the small intestine is brought to the surface of the abdomen to form a stoma. An end ileostomy can be temporary or permanent.

The temporary solution is relevant in situations where the diseased part of the bowel has been removed and the remaining part needs to rest before the ends are joined together. The permanent solution is chosen in situations where it is too risky or not possible to reconnect the two parts of the intestine.

Loop ileostomy

In a loop ileostomy, a loop of the small intestine is lifted above skin level and held in place with a stoma rod. A cut is made on the exposed bowel loop, and the ends are then rolled down and sewn onto the skin. In this way, a loop ileostomy actually consists of two stomas that are joined together.

The loop ileostomy is typically temporary and performed to protect a surgical join in the bowel. If temporary, it will be closed or reversed in a later operation.

Urostomy surgery

Urostomy

If the bladder or urinary system is damaged or diseased and your patient is unable to pass urine normally, there is a need for a urinary diversion. This is called a urostomy, an ileal conduit or a Bricker bladder.

An isolated part of the intestine is brought onto the surface of the right-hand side of the abdomen and the other end is sewn up. The ureters are detached from the bladder and reattached to the isolated section of the intestine. Because this section of the intestine is too small to function as a reservoir, and there is no muscle or valve to control urination, your patient will need a urostomy pouch to collect the urine.

Ostomy Skin Tool

Your opportunity to assess peristomal skin conditions in a unique standardized way

Designed for - and by - ostomy care nurses

The Ostomy Skin Tool was developed in collaboration with the professional Coloplast Global Advisory Board, which includes highly qualified ostomy care nurses from 12 different countries.

The tool was developed for the DialogueStudy, a global clinical study, to assess the condition of peristomal skin over time. It has been tested in practice by the members of the Coloplast Global Advisory Board and some of their colleagues before being introduced into the DialogueStudy.

The Ostomy Skin Tool consists of two parts; the DET score and the AIM diagnostic guide.

As the Ostomy Skin Tool is a novel, standardized tool for assessing peristomal skin conditions over time, it is vital to understand how the Ostomy Skin Tool works and to prove replicability.

Try the online version of the Ostomy Skin Tool below - simply click the UK flag below to start.

Peristomal skin disorders

Monitoring of peristomal skin, already during the post-operative phase, is essential to ensure that the skin remains healthy, and, if it is affected by a skin disorder, that appropriate and consistent treatment can be initiated immediately.

The Ostomy Skin Tool is developed together with stoma care nurses on the Global Advisory Board to ensure accurate assessment of peristomal skin.

AIM guide (Assessment, Intervention, Monitoring) - provides categorisation of the peristomal skin disorder according to its cause and offers guidance on care. The guide is based on a thorough literature review.

The tool is designed to help you to:

Assess peristomal skin at the time of assessment based on the validated DET score

Identify the most suitable appliance and peristomal skin care routine

Provide you and your colleagues with a common language for describing peristomal skin conditions

Peristomal Skin Conditions

Hyperplasia (Pseudoverrucous Lesions)

Most often seen with urostomies. The wart-like lesions are usually caused by urine pooling on the skin for extended periods of time.

Prevention:

Correctly cut the barrier to the size of the stoma

Assess for leakage. Examine ostomy barrier for erosion upon removal and adjust wear time accordingly

Consider using an extended wear barrier

If stoma is flush or retracted, consider a pouching system with convexity

Use a pouch that has a built-in anti-reflux valve to prevent urine from washing over the stoma

Use a bedside drainage system at night

Management:

Consult physician or ET Nurse

Identify the underlying cause

Modify the pouching system

Check urine pH to assess urine acidity

Physician’s orders may include white vinegar soaks and/or a Colly-Seel-type barrier to the wart-like lesions until the condition improves

Fungal Infection (Candida / Yeast)

Candida is a common skin flora that grows in dark, damp sites such as under an ostomy barrier. The rash starts out as pustules before turning into a raised area with erythema consisting of irregular margins with surrounding satellite lesions. Patients may complain of itching or burning. Predisposing factors include antibiotic therapy, diabetes or immunosuppression.

Prevention:

Use a properly fitting pouching system

Eliminate cause of moisture: inspect pouching system for signs of leakage

After bathing, dry the skin and the pouching system thoroughly

Assess wear time by examining the barrier for erosion upon removal

Management:

Consult with physician or ET Nurse

Identify the underlying cause

If skin is moist and weepy, consider the crusting technique using antifungal powder in place of ostomy powder (first obtain physician's order / prescription)

Systemic treatment may be prescribed by the physician if more than one body area is involved

Blood sugar management may also be considered

Folliculitis

Folliculitis is an inflammation of a hair follicle. It is often caused by bacterial sources such as staphylococcus aureus, streptococci and pseudomonas aeruginosa. Predisposing factors include antibiotic therapy, diabetes and immunosuppression.

Prevention:

Gently remove the barrier to prevent skin trauma

Shave hair in the direction of hair growth, but always away from the stoma

Use an electric razor

Wash, rinse and completely dry skin before applying a new pouching system

Management:

Consult with physician or ET Nurse

Identify the underlying cause

Avoid shaving hair in affected area - clip hair only

If skin is moist and weepy, consider the crusting technique using ostomy powder or an antifungal powder (first obtain physician’s order/prescription) if a fungal rash is present

Remove the barrier in the direction of hair growth using the push-pull technique

Use warm water or adhesive remover to remove the barrier if needed

Evaluate pouching system to ensure proper fit

Management:

Consult with physician or ET Nurse

If skin is moist and weepy, consider the crusting technique

Irritant Contact Dermatitis

Hypersensitivity to chemical agents such as stoma output, soaps and/or adhesives resulting in an inflammatory response. Associated with well-defined erythema, edema or loss of epidermis. Pruritus, crusting, oozing or dryness may be present.

Common stomal challenges

Prolapse

A prolapse occurs when the bowel telescopes through the stoma, causing the stoma to increase in length. It is most common with loop colostomies. Contributing factors include: abdominal wall opening larger than the bowel, increased abdominal pressure and weak abdominal tone.

Measure stoma base while stoma is protruding at its largest size (sitting position)

Cut barrier opening to accommodate stoma at its largest size

Use a flexible, flat barrier

Instruct patient to notify physician for signs and symptoms of obstruction and ischemia

Parastomal Hernia

Occurs due to a weakness in the muscle layer of the abdominal wall, allowing intestine to come through the muscle. Contributing factors include a too-large fascial opening around the stoma, poor muscle tone and placement of the stoma outside the rectus muscle.

Management:

Consult with physician or ET Nurse

Measure the stoma while patient is sitting up and stoma is at its largest

Use a one-piece pouching system or a two-piece adhesive coupling system, which allows flexibility and adapts to abdominal contours

Consider a hernia support belt for added support

Instruct patient to avoid excessive weight gain

Mucocutaneous Separation

The sutured junction between the stoma and the skin is called the mucocutaneous junction. When the junction completely or partially separates from the skin, it is called a mucocutaneous separation. Contributing factors include infection, tension on the suture line and delayed healing due to disease processes or corticosteroids.

Management:

Consult with physician or ET Nurse

Wound care may be ordered by the physician and is determined by amount of drainage and depth of wound

Change pouching system as needed to provide wound care

Necrosis

Occurs due to a reduction of blood flow to the stoma affecting stoma viability. Contributing factors include edema of the bowel wall, extensive tension on the mesentery, obesity and too tight or closely placed sutures. Necrosis typically occurs within the first 5 days post-op.

Management:

Consult with physician or ET Nurse

Use a transparent, two-piece pouching system for closer inspection of the stoma

Size the barrier appropriately to prevent constriction

Resize the barrier as nonviable tissue sloughs and stoma contracts

Use an ostomy appliance deodorant while necrotic stoma is sloughing off if needed